Vein Ablation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that a patient has requested reimbursement for injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (e.g., great saphenous vein, accessory saphenous vein), same leg. As reported in the current medical literature pertaining to the use of the Varithena procedure, the procedure has been demonstrated to be useful in treating lower extremity varicose veins with a high degree of success. The Varithena procedure was evaluated in two pivotal trials with the primary goal of improvement in varicose vein symptoms, supported by its indications. Clinical trial efficacy also included improvement in the appearance of varicose veins and physiological response to treatment.

Nature of Statutory Criteria/Case Summary: The patient is a 52-year-old male with symptoms of edema, fatigue, aches/pains, and cramps in the lower extremities. Findings: The physician reviewer found that an ultrasound performed showed reflux of over 1000 ms in the greater saphenous vein (GSV) of the right and left legs, and a refluxing perforator vein in the right and left legs. The ankle brachial indices, pulse volume recording, and arterial ultrasound performed were all normal. The patient was prescribed compression stockings. On ------ the patient reported continued symptoms of edema, fatigue, and bulging veins. A repeat venous ultrasound of the legs showed the same findings as the study on -------. The patient has requested coverage for endovenous ablation therapy of incompetent veins right and left.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hybrid Maze procedure. This patient presents with paroxysmal atrial fibrillation with intermittent palpitations, an EF of 45%, and mild enlargement of left atrium. His provider has recommended a hybrid Maze procedure. The convergent, or hybrid Maze procedure, is a surgical ablation option for patients with atrial fibrillation that is considered when medical therapy and percutaneous ablative options have proven ineffective. When ablation is indicated, current guidelines do not recommend a hybrid surgical approach to ablation over conventional percutaneous ablation (Calkins, et al.). A hybrid approach to ablation has not been shown to be superior to existing accepted approaches in the treatment of atrial fibrillation.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ablation with varicose vein clogging. In this case, the plan for bilateral saphenous ablation has been made prior to identifying reflux in the saphenous veins. The patient’s edema and varicose veins are both described as mild. The vast majority of the right great saphenous vein is without reflux. The patient has documented peripheral artery disease with ulceration, potentially representing a limb-threatening condition due to arterial ischemia. The appropriateness of saphenous vein ablation in this setting cannot be supported.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Vein Ablation, then check the rights and deadlines that apply to your plan.